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Adopting a multidisciplinary telemedicine intervention for fall prevention in Parkinson's disease. Protocol for a longitudinal, randomized clinical trial.
Cubo, E, Garcia-Bustillo, A, Arnaiz-Gonzalez, A, Ramirez-Sanz, JM, Garrido-Labrador, JL, Valiñas, F, Allende, M, Gonzalez-Bernal, JJ, Gonzalez-Santos, J, Diez-Pastor, JF, et al
PloS one. 2021;(12):e0260889
Abstract
BACKGROUND Approximately 40-70% of people with Parkinson's disease (PD) fall each year, causing decreased activity levels and quality of life. Current fall-prevention strategies include the use of pharmacological and non-pharmacological therapies. To increase the accessibility of this vulnerable population, we developed a multidisciplinary telemedicine program using an Information and Communication Technology (ICT) platform. We hypothesized that the risk for falling in PD would decrease among participants receiving a multidisciplinary telemedicine intervention program added to standard office-based neurological care. OBJECTIVE To determine the feasibility and cost-effectiveness of a multidisciplinary telemedicine intervention to decrease the incidence of falls in patients with PD. METHODS Ongoing, longitudinal, randomized, single-blinded, case-control, clinical trial. We will include 76 non-demented patients with idiopathic PD with a high risk of falling and limited access to multidisciplinary care. The intervention group (n = 38) will receive multidisciplinary remote care in addition to standard medical care, and the control group (n = 38) standard medical care only. Nutrition, sarcopenia and frailty status, motor, non-motor symptoms, health-related quality of life, caregiver burden, falls, balance and gait disturbances, direct and non-medical costs will be assessed using validated rating scales. RESULTS This study will provide a cost-effectiveness assessment of multidisciplinary telemedicine intervention for fall reduction in PD, in addition to standard neurological medical care. CONCLUSION In this challenging initiative, we will determine whether a multidisciplinary telemedicine intervention program can reduce falls, as an alternative intervention option for PD patients with restricted access to multidisciplinary care. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04694443.
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Comparative effectiveness of team-based care with a clinical decision support system versus team-based care alone on cardiovascular risk reduction among patients with diabetes: Rationale and design of the D4C trial.
Shi, X, He, J, Lin, M, Liu, C, Yan, B, Song, H, Wang, C, Xiao, F, Huang, P, Wang, L, et al
American heart journal. 2021;:45-58
Abstract
BACKGROUND Diabetes has become a major public health challenge worldwide, especially in low- and middle-income countries (LMICs). Uncontrolled hyperglycemia, hypertension, and dyslipidemia major risk factors for all-cause mortality and cardiovascular disease (CVD) are common in patients with diabetes in China. We propose to compare the effectiveness of team-based care plus a clinical decision support system (CDSS) with team-based care alone on glycemic, blood pressure (BP), and lipid control, and clinical CVD reduction among patients with type-2 diabetes and at high risk for CVD. METHODS The Diabetes Complication Control in Community Clinics (D4C) study is a cluster-randomized trial conducted among 38 community health centers in Xiamen City, China. Nineteen clinics have been randomly assigned to team-based care plus CDSS and 19 to team-based care alone. Team-based care includes primary care providers, health coaches, and diabetes specialists working collaboratively with patients to achieve shared treatment goals for CVD risk factor reduction. The CDSS integrates guideline-based treatment algorithms for glycemic, BP, and lipid control, along with a patient's medical history and insurance policy, to recommend treatment and follow-up plans. In phase 1, the co-primary outcomes are mean reduction in glycated hemoglobin (HbA1c), systolic BP (SBP), and low-density lipoprotein (LDL)-cholesterol over 18 months, and the proportion of patients with controlled HbA1c, SBP, and LDL-cholesterol at 18 months' between the 2 comparison groups. In phase 2, the primary outcome is the difference in major CVD incidence (non-fatal stroke, non-fatal myocardial infarction, hospitalized heart failure, and CVD mortality) between the 2 comparison groups. Mean reduction in HbA1c, SBP, and LDL-cholesterol levels will be simultaneously modeled for a single overall treatment effect. CONCLUSION The D4C trial will generate evidence on whether a CDSS will further reduce the CVD burden among patients with diabetes beyond team-based care at community clinics. If proven effective, this implementation strategy could be scaled up within primary care settings in China and other LMICs to reduce CVD incidence and mortality among patients with diabetes.
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Reducing Emergency Department Visits Among Patients With Diabetes by Embedding Clinical Pharmacists in the Primary Care Teams.
Moreno, G, Fu, JY, Chon, JS, Bell, DS, Grotts, J, Tseng, CH, Maranon, R, Skootsky, SS, Mangione, CM
Medical care. 2021;(4):348-353
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Abstract
BACKGROUND Pharmacists are effective at improving control of cardiovascular risk factors, but it less clear whether these improvements translate into less emergency department (ED) use and fewer hospitalizations. The UCMyRx program embed pharmacists in primary care. OBJECTIVE The objective of this study was to examine if the integration of pharmacists into primary care was associated with lower ED and hospital use for patients with diabetes. DESIGN This was a quasi-experimental study with a comparator group. SUBJECTS The analytic sample included patients with diabetes with uncontrolled cardiovascular risk factors (A1C >9%, blood pressure >140/90 mm Hg, low-density lipoprotein-cholesterol >130 mg/dL) who had 1 or more visits in either a UCMyRx (648 patients, 14 practices) or usual care practice (1944 patients, 14 practices). MEASURES Our outcomes were ED and hospitalization rates as measured before and after the consultations between UCMyRx and usual care. Our predictor variable was the pharmacist consultation. Poisson generalized estimating equations model was used to estimate the adjusted predicted change in utilization before and after the pharmacist consultation. The Average Treatment Effect on the Treated was estimated. RESULTS In models adjusted, the adjusted mean predicted number of emergency department visits/month during the year before the consultation was 0.09 among UCMyRx patients. During the year after initiating the care with the pharmacists, this rate decreased to an adjusted mean monthly rate of 0.07, with an Average Treatment Effect on the Treated=0.021 (P=0.035), a predicted reduction of 21% in emergency department visits associated with the clinical pharmacist consults. There was a nonsignificant predicted 3.2% reduction in hospitalizations over time for patients in the UCMyRx program. CONCLUSION Clinical pharmacists are an important addition to clinical care teams in primary care practices and significantly decreased utilization of the ED among patients with poorly controlled diabetes.
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Effectiveness of Multidisciplinary Care for Chronic Kidney Disease: A Systematic Review.
Hsu, HT, Chiang, YC, Lai, YH, Lin, LY, Hsieh, HF, Chen, JL
Worldviews on evidence-based nursing. 2021;(1):33-41
Abstract
BACKGROUND Chronic kidney disease (CKD) is a common chronic disease. As this disease is extremely complex, multidisciplinary care (MDC) is needed to provide complete and continuous care. AIM: A systematic literature review was performed to examine the constituents of MDC, the content of MDC interventions, and the health outcomes in CKD patients receiving MDC. METHODS Searches of five Chinese and English databases for studies of CKD patients who had received MDC from 2007 to 2019 revealed 11 studies, which comprised 16,066 CKD patients. The Physiotherapy Evidence Database scale (Physiotherapy Evidence Database, 2017) was used to appraise study quality for randomized controlled trials, and the Joanna Briggs Institute Critical Appraisal tools (Joanna Briggs Institute, 2017) were for cohort studies. RESULTS The MDC teams that provided comprehensive medical care for these patients included nephrologists, nurses, surgeons, general practitioners, pharmacists, psychotherapists, social workers, nutritionists, and other specialists. The literature review revealed that MDC for CKD slows the decline in estimated glomerular filtration rate and decreases patient mortality, the risk of renal replacement therapy, the need for emergent dialysis, and annual medical costs. Analyses of biochemical markers in the CKD patients showed that MDC improves control of serum levels of calcium and phosphate, improves control of parathyroid hormone, and reduces proteinuria and fasting blood glucose values. However, further studies are needed to determine the effects of MDC on all-cause mortality, blood pressure control, hospitalization rate, hospitalization for cardiovascular or infection events, medications use, and other biochemical markers in CKD patients. LINKING EVIDENCE TO ACTION Cross-disciplinary collaboration of healthcare professionals is needed to ensure that patients undergo regular follow-up and periodic assessment of clinical status, in addition to ensuring that relevant resources and assistance are provided in a timely manner. A follow-up period of at least 2 years is also needed to ensure sufficient time to observe MDC results.
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Economic benefit of dietetic-nutritional treatment in the multidisciplinary primary care team.
Casas-Agustench, P, Megías-Rangil, I, Babio, N
Nutricion hospitalaria. 2020;(4):863-874
Abstract
Chronic diseases and aging are placing an ever increasing burden on healthcare services worldwide. Nutritional counselling is a priority for primary care because it has shown substantial cost savings. This review aims to evaluate the evidence of the cost-effectiveness of nutritional care in primary care provided by health professionals. A literature search was conducted using PubMed/MEDLINE between January 2000 and February 2019. The review included thirty-six randomized controlled trials (RCTs) and systematic reviews conducted in healthy people and people with obesity, type-2 diabetes mellitus, cardiovascular risk or malnutrition. All the RCTs and reviews showed that nutritional intervention led by dietitians-nutritionists in people with obesity or cardiovascular risk factors was cost-effective. Dietary interventions led by nurses were cost-effective in people who needed to lose weight but not in people at high cardiovascular risk. Some dietary changes led by a primary care team in people with diabetes were cost-effective. Incorporating dietitians-nutritionists into primary care settings, or increasing their presence, would give people access to the healthcare professionals who are best qualified to carry out nutritional treatment, and may be the most cost-effective intervention in terms of health expenditure. Notwithstanding the limitations described, this review suggests that incorporating dietitians-nutritionists into primary health care as part of the multidisciplinary team could be regarded as an investment in health. Even so, more research is required to confirm the conclusions.
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Defining a new model of interdisciplinary cancer cachexia care in regional Victoria, Australia.
Vaughan, VC, Farrell, H, Lewandowski, PA, McCoombe, SG, Martin, P
Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer. 2020;(7):3041-3049
Abstract
PURPOSE Cachexia is a wasting condition affecting approximately 50% of cancer patients, associated with decreased quality of life and survival. Barwon Health's Cachexia and Nutrition Support Service provides person-centred interdisciplinary care to assist the management of cachexia symptoms. This study describes a novel and effective service model established in a regional cachexia clinic and the patient population it serves. METHODS A descriptive, retrospective longitudinal study was conducted of records from patients attending Barwon Health between 2008 and 2013 (n = 175), alongside the description of service refinement over this time. Patients with ≥ 2 attendance dates were assessed for anthropometric measures, follow-up intervals, and muscle function outcomes to describe patient trajectory during clinic involvement. RESULTS This is the first detailed description of a successful interdisciplinary clinic specific to cancer cachexia management, where patients are seen outside established 8- to 12-week structured programs which prevail in other cachexia clinics. Seventy-five patients (43%) attended one appointment only, with almost half of these (n = 33) first attending within 60 days of death. Of the 99 patients with two or more appointments, 49% displayed positive outcomes with > 2-kg weight gain between two consecutive appointments, and > 50% improved functional strength between two consecutive appointments. CONCLUSIONS The majority of patients attending clinic multiple times maintained or increased weight and functional status during their involvement with the service. However, successes of care provision were muted by high attrition, primarily due to delayed referral and expected high mortality within the study cohort. Planned future analyses with greater patient numbers and cancer stratification will establish cachectic populations most likely to benefit from this novel mode of interdisciplinary care. The Cachexia and Nutrition Support Service provides an effective and efficient service model for the provision of specialist cachexia care to community-dwelling patients in regional Australia.
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Participation of pulmonary embolism response teams during the perioperative period.
Porres-Aguilar, M, Anaya-Ayala, JE, Grimaldo-Gómez, FA, Santos-Martínez, LE, Jiménez, D, Porres-Muñoz, M, Izaguirre-Ávila, R, Carrillo-Esper, R
Archivos de cardiologia de Mexico. 2020;(3):321-327
Abstract
La tromboembolia pulmonar aguda representa una causa frecuente de morbimortalidad cardiovascular, sólo rebasada por los síndromes coronarios agudos y la enfermedad cerebrovascular. El inicio y la intervención de un equipo multidisciplinario de respuesta rápida en la tromboembolia pulmonar son imperantes para mejorar el pronóstico y reducir al mínimo las posibles secuelas en el subgrupo de pacientes más graves. En este artículo de revisión se describe y revisa de manera general el papel actual y potencial que tienen dichos equipos de respuesta rápida, con un enfoque particular en el perioperatorio. Acute pulmonary embolism represents a frequent cause of cardiovascular morbidity and mortality, only exceeded by acute coronary syndromes and cerebrovascular disease. The start-up and implementation of a designated pulmonary embolism response team is necessary to improve prognosis and minimize long-term sequelae in the subgroup of patients with significant pulmonary embolism. Herein, we describe and discuss an overview of the current and potential role of pulmonary embolism response teams, with a focus on the perioperative period.
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Improvements in the multidisciplinary care are beneficial for survival in amyotrophic lateral sclerosis (ALS): experience from a tertiary ALS center.
Klavžar, P, Koritnik, B, Leonardis, L, Dolenc Grošelj, L, Kirbiš, M, Ristić Kovačič, S, Klinar, P, Pohar Perme, M, Zidar, J
Amyotrophic lateral sclerosis & frontotemporal degeneration. 2020;(3-4):203-208
Abstract
Objective: The Ljubljana ALS Centre, established in 2002, is the only tertiary center for amyotrophic lateral sclerosis (ALS) in Slovenia. The aim of our study was to evaluate the impact of therapeutic interventions and improvements in the multidisciplinary care on the survival of our patients.Methods: All patients diagnosed with ALS at our center during years 2003-2005 (early group) and 2011-2012 (late group) were included in this retrospective cohort study (n = 124). Kaplan-Meier survival analysis and multiple regression analysis with Cox proportional hazards model were performed to compare survival and to evaluate the differences between the two cohorts.Results: Median survival from the time of diagnosis was 13.0 (95% CI 10.2-15.8) months in the early group and 21.8 (95% CI 17.2-26.4) months in the late group (p = 0.005). In the Cox proportional hazards analysis, the late group of patients was associated with better survival independently of all other prognostic factors (hazard ratio (HR)=0.51, 95% CI = 0.32-0.81, p = 0.004). Survival was also associated with patients' age, use of noninvasive ventilation (NIV) and gastrostomy. The model fit significantly improved when the interaction between the NIV use and the observed time period was added to the model (HR = 0.34, 95% CI = 0.12-0.96, p = 0.041).Conclusions: Our findings suggest that improvements in the multidisciplinary care were beneficial for survival of our patients with ALS. The survival benefit in the late group of our patients could be partially explained by the improvements in the NIV use at our center.
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Improving Outcomes Among Young Adults with type 1 diabetes: The D1 Now Randomised Pilot Study Protocol.
Casey, B, Byrne, M, Casey, D, Gillespie, P, Hobbins, A, Newell, J, Morrissey, E, Dinneen, SF
Diabetic medicine : a journal of the British Diabetic Association. 2020;(9):1590-1604
Abstract
BACKGROUND Young adults (18-25 years old) living with type 1 diabetes mellitus often have sub-optimal glycaemic levels which can increase their risk of long term diabetes complications. Informed by health psychology theory and using a (public and patient involvement) young adult-centred approach, we have developed a complex intervention, entitled D1 Now, to improve outcomes in this target group. The D1 Now intervention includes three components; 1) a support-worker, 2) an interactive messaging system and 3) an agenda setting tool for use during clinic consultations. AIMS The aim of the D1 Now pilot study is to gather and analyse acceptability and feasibility data to allow us to (1) refine the D1 Now intervention, and (2) determine the feasibility of a definitive Randomised Control Trial (RCT) of the intervention. METHODS Diabetes clinics on the island of Ireland will be recruited and randomised to a D1 Now intervention arm or a usual care control arm. For a participant to be eligible they should be 18-25 years old and living with type 1 diabetes for at least 12 months. Participant outcomes (influenced by a Core Outcome Set) include change in HbA1c, clinic attendance, number of episodes of severe hypoglycaemia and of diabetic ketoacidosis, diabetes distress, self-management, quality of life and perceived level of control over diabetes; these will be will be measured at baseline and after 12 months follow-up for descriptive statistics only. An assessment of treatment fidelity, a health economic analysis and a qualitative sub-study will also be incorporated into the pilot study. ISRCTN (ref: ISRCTN74114336).
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Acute medical stabilisation of adults with anorexia nervosa: experience of a defined interdisciplinary model of care.
Braude, MR, Con, D, Clayton-Chubb, D, Nandurkar, R, Chua, LE, Newnham, ED
Internal medicine journal. 2020;(1):77-85
Abstract
BACKGROUND Patients with anorexia nervosa (AN) are vulnerable to physiological decompensation and often require inpatient management by an eating disorders unit. AIMS Patients admitted to an Australian tertiary medical centre for medical stabilisation of AN were assessed as part of quality assurance. Analysis included: (i) medical complications during acute inpatient stabilisation; (ii) predictors of refeeding syndrome; (iii) predictors governing length of stay (LOS); and (iv) outcomes pre- and post-implementation of multidisciplinary treatment guidelines. METHODS A retrosepctive analysis of 95 consecutive admissions (60 individual patients) between November 2011 and August 2017 was performed. RESULTS Patients had a median LOS of 9.6 days (interquartile range 5.8-19.7) and a mean weight gain of 1.4 kg (standard deviation 2.9). Medical complications included the following: hypoglycaemia (11.6%) and refeeding electrolyte derangement (26.3%). Advancing age (odds ratio (OR) 1.06 per year, P = 0.019), nasogastric tube requirement (OR 3.4, P = 0.014) and Code Grey(s) (security calls) (OR 7.1, P = 0.010) were associated with refeeding electrolyte derangement. Parameters associated with increased LOS included the following: lower body mass index (P = 0.029), Code Grey(s) (P = 0.029) and tachycardia (P = 0.013). Following multivariate analysis, the post-guidelines implementation group required less intravenous fluid and electrolyte replacement, though had lower rates of refeeding electrolyte derangement (OR 0.33 (0.11-0.99)). CONCLUSION Patients with moderate to severe AN are at risk of dangerous medical complications, and older patients may have heightened predisposition to refeeding electrolyte derangement. Early identification of medically high-risk patients is imperative to implement timely, life-saving interventions.